We take evidence-based models and concepts from behavior change science, adapt them for the healthcare setting, and integrate them where it makes sense. All of our suggested interventions have been tested and proven in a real-world practice.
Here are some of the models and concepts that we use in our interventions, which can be integrated into online programs, written materials, or personal interactions. For examples on how we apply these into real practice, check out our Results section.
Please click on the following behavior change science topics to learn more.
Multiple reviews of literature indicate motivational interviewing (MI) is the most standardized and researched health coaching approach, and the only one to be consistently associated with positive clinical outcome).1-4 As described by founders, Miller and Rollnick:5 “Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation of and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion." There are over 900 clinical trials completed or in progress6 that demonstrate the efficacy of the MI approach in improving patient engagement, self-care, and adherence to treatment plan; all resulting in improved clinical outcomes.
Patient activation refers to an individual’s sense of empowerment to take control of his or her health. It consists of knowledge, skills, attitudes and confidence about managing one’s health and/or chronic conditions. Hibbard et al.7 succinctly summarize the review of activation literature as indicating that: ”… patients who are able to: (1) self-manage symptoms/problems; (2) engage in activities that maintain functioning and reduce health declines; (3) be involved in treatment and diagnostic choices; (4) collaborate with providers; (5) select providers and provider organizations based on performance or quality; and (6) navigate the health care system, are likely to have better health outcomes.” Clinicians can be trained to address and improve activation levels of their clients/patients through MI-based health coaching interventions.8-10
Personal or self-agency is defined as the understanding of oneself as an agent who is capable of having an influence over one’s own motives, behavior, and possibilities. In the context of behavior change science, it is the belief that what I do matters, e.g., if I walk daily, I can stay healthy and live longer. One group of researchers found that employees with chronic conditions that had declined to join a health management program had lower levels of self-agency than those who had joined the program.11 An example of a patient with low self-agency is a woman with diabetes who does not take her prescribed medications or check blood sugars regularly because she does not believe doing so will help her stay healthy or avoid diabetes-related complications.
Self-efficacy refers to an individual’s confidence in managing his or her health or changing a health habit. Self-efficacy can exert a powerful influence on how successful we are in achieving important health or life goals. In fact, Lorig et al.12 found that self-efficacy levels may predict clinical outcomes better than actual health behaviors. For example, many patients realize that quitting smoking is important to their health, but, based on their previous attempts, lack the confidence that they can quit. This lack of confidence may keep patients from even trying to quit again unless self-efficacy is addressed. There are a number of interventions that target self-efficacy or self-efficacy-related beliefs, such as cognitive-behavioral therapy and motivational interviewing.13
Stages of Change
The stages of change is a component from the Transtheoretical Model (TTM). Developed by James Prochaska, TTM is one of the most enduring and well-known behavior change model.1The foundational principle of the TTM is that the change process can be divided into separate stages of readiness. By using approaches that match a patient’s level of change readiness, the practitioner can facilitate and accelerate movement through precontemplation, contemplation, preparation, action, and maintenance. Inherent in this model is the acceptance of relapse as a normal part of the change process and, secondly, the belief that individuals can move forward in change readiness with the assistance of a skilled practitioner. The TTM model proposes that in order for people to progress they need: (1) a growing awareness that the advantages (the “Pros”) of changing outweigh the disadvantages (the “Cons”), or decisional balance; and (2) the confidence or self-efficacy that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behavior. For a detailed overview of the TTM, go to the Cancer Prevention Research Center Website.
Change Talk vs. Sustain Talk
Some of the most exciting research in behavior change science has been in the last ten years illuminating the importance of change talk from a client considering change. The MI approach emphasizes the language of change and strategies to evoke and reinforce change talk – desire, ability, reasons and need for change – rather than the pursuit of sustain talk, or barriers/challenges associated with the change or treatment plan.15 Back in 1972, Bem made the case for Self-Perception Theory; that individuals come to know their own attitudes, emotions, and motivations by observing their own behaviors or listening to their own arguments for or against change. Recently, this theory has been reinforced by intriguing research using non-invasive brain imaging (magnetoencephalography) to demonstrate that an individual processes their own change talk and sustain talk differently in the brain; supporting the theory that hearing oneself verbalize change talk sparks brain activity in the lobe associated with self-perception, which supports higher levels of commitment and activation towards change.16 Indeed, current wisdom informs us that the current traditional mode of addressing non-adherent behavior from patients by lecturing and directing induces resistance to change and should be considered the worst case scenario in health coaching; whereas, the practice of evoking and reflecting the patient’s own reasons for motivation and change is correlated with positive clinical outcomes and should be considered the best case scenario in health coaching.17
Shared Decision Making (SDM) is a patient-centered approach, as opposed to the traditional practice of clinicians dictating decisions on behalf of the patient. Effective SDM increases patient engagement and activation, as well as increasing the odds of a conservative choice.18 Elwyn et al.19 defines SDM as “… an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.” Effective SDM requires: (1) providing information about specific options, including an objective and transparent sharing of risks and benefits; (2) eliciting, clarifying, and validating patient goals and preferences; and (3) carrying out an interactive process of reflection and discussion based on those preferences to arrive at a shared decision. There are many aids that have been developed to assist in the process, both for online activities and in-person discussions. For more information about these decision aids, see a 2014 Cochrane review.
Incentives vs. Disincentives
There is an immense body of literature about the potential role that incentives and/or disincentives can play in patient engagement and activation. Here is a high level overview.
- Incentives can catch people’s attention and improve enrollment rates in health management programs and health competitions.
- Incentives can increase participation in one-time events such as health appraisals, vaccinations or preventive screenings.
- Incentives can improve success with short-term behavior change such as quitting smoking during pregnancy.
- Disincentives are not effective as a patient engagement strategy.
- Cost-sharing (a type of disincentive) decreases quality of care for the sickest and poorest, as well as decreases participation in preventive services and medication compliance.
- Incentives are not as effective for entrenched, complex behavior changes such as weight loss or smoking unless there is a very large monetary amount or if the behavior is time-limited (e.g., during pregnancy); the effect of the incentives diminishes as the reward disappears.
- Incentives can significantly decrease intrinsic motivation when used as tangible rewards that are contingent upon the individual completing the behavior or reaching success; this effect runs directly in opposition to the goal of activating or empowering individuals with chronic conditions.
For a comprehensive discussion of incentives and disincentives in healthcare, including references, see this Oregon Health Authority document, and scroll down to page 66.
Research from the behavioral economics domain holds the potential to improve our efforts in healthcare to market healthy lifestyle choices and preventive care to patients. By crafting messages that get people’s attention and influence behavior, we can improve our outreach efforts and patient engagement. One strategy that we can borrow from the behavioral economics literature comes from Loss Aversion Theory. The research on this model tells us that people are willing to take action and risk more when the choice is posed as a loss. In one study, every single participant was influenced by the way that economically identical options were framed – they took more risk to avoid loss.20 For example, rather than framing a message that states that “Join xyz program and we will improve your health, plus save you $50 a month”; reframe it as “Don’t lose out on $50 a month – join xyz program and protect your health.” By being more deliberate about our patient materials, incentives, and outreach efforts, plus using evidence-based methods, we can complement our other patient engagement interventions.
1 Butterworth SW, Linden A, McClay W. Health Coaching as an Intervention in Health Management Programs. Disease Management & Health Outcomes 2007;15(5):299-307.
2 Noordman J, van der Weijden T, van Dulmen S. Communication–related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Educ Couns 2012;89(2):227-44.
3 Olsen JM, Nesbitt BJ. Health Coaching to Improve Healthy Lifestyle Behaviors: An Integrative Review. American Journal of Health Promotion 2010;25(1):e1-e12.
4 Wolever RQ, Simmons LA, Sforzo GA, et al. A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral intervention in Healthcare. Globl Adv Health Med 2013;2(4):38-57.
5 Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Third Edition. New York: Guilford Publ.; 2013.
6 National Center for Biotechnology Information, U.S. National Library of Medicine. Key word: motivational interviewing; Article type: Clinical Trial. Accessed on October 23, 2016 at https://www.ncbi.nlm.nih.gov/pubmed
7 Hibbard JH, Stockard J, Mahoney ER, et al. Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Serv Res 2004;39(4p1):1005-1026.
8 Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. J Eval Clin Prac 2010;16(1):166-174.
9 Linden A, Butterworth SW. A Comprehensive Hospital-Based Intervention to Reduce Readmissions for Chronically Ill Patients: A Randomized Controlled Trial. Am J Man Care 2014;20(10):783-792.
10 Skolasky RL, Maggard AM, Li D, et al. Health Behavior Change Counseling in Surgery for Degenerative Lumbar Spinal Stenosis. Part I: Improvement in Rehabilitation Engagement and Functional Outcomes. Arch Phys Med Rehab 2015;96(7):1200-1207.
11 Butterworth SW, Prochaska JO, Redding CA. Evaluation of Project META (Motivating Employees Towards Action). Research Presentation to 2010 Art & Science of Health Promotion Conference, Hilton Head, SC; March 2010.
12 Lorig KR, Hurwicz ML, Sobel D, et al. A national dissemination of an evidence-based self-management program: a process evaluation study. Pat Educ Couns 2005;59(1):69-79.
13 Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. J Eval Clin Prac 2010;16(1):166-174.
14 Prochaska JO, Redding CA, Evers KE. (2008). The Transtheoretical Model and stages of change. In K. Glanz, B. K. Rimer & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 97-121). San Francisco: Jossey-Bass.
15 Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Third Edition. New York: Guilford Publ.; 2013.
16 Houck JM, Moyers TB, Tesche CD. Through a glass darkly: Some insights on change talk via magnetoencephalography. Psych Addic Behav 2013;27(2):489–500.
17 Butterworth, SW. Motivational Interviewing Health Coaching. Chronic Care Professional (CCP) Health Coaching Certification Manual 2013; HealthSciences Institute, St. Petersburg.
18 Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2011 May.
19 Elwyn G, Frosch D, Thomson R, et al. Shared Decision Making: A Model for Clinical Practice. J Gen Intern Med 2012;27(10):1361-1367.
20 De Martino B, Kumaran D, Seymour B, Dolan RJ. Frames, Biases, and Rational Decision-Making in the Human Brain. Science 2006;313(5787):684-687.